ONCOLOGY



ONCOLOGY

ESSENTIAL CONCEPTS OF CANCER

NURSING MANAGEMENT OF PATIENTS WITH CANCER

Cancer Defined

A disease process that begins when an abnormal cell is transformed by the genetic mutation of cellular DNA (Normal cells mutate into abnormal cells)

Group of complex diseases; affect different organs and organ systems

The abnormal cells have invasive characteristics and infiltrate other tissues. This phenomenon is metastasis.

Cancer cells are described as malignant. These cells demonstrate uncontrolled growth that does not follow physiologic demand.

Oncology

Study of cancers

Oncology nurses specialize in the care, treatment of clients with cancer

Incidence and Prevalence

Cancer accounts for about 25% of death on yearly basis

Three most common types of cancer

Among males:

Prostate,

Lung, bronchial

Colorectal

Among females:

Breast

Lung and bronchial

Colorectal

Incidence

Incidence rate of all cancers

All Jordanians (2003) 72.9/100.000

Male Jordanian 70.7/100.000

Female Jordanian 75.2/100.000

Comparison among Countries

Country Male Female

Algeria 111.0 69.2

Kuwait 106.7 127.3

Denmark 327.0 304.9

Ireland 316.6 267.2

USA, white 385.0 273.6

USA, Black 450.5 253.7

Jordan 137.6 134.3

Cancer incidence by site and sex in USA (1994)

Male Type Percent

Prostate 32

Lung 16

Colon or rectum 12

Urinary Tract 9

Leukemia and lymphoma 7

Female

Breast 32

Colon and rectum 13

Lungs 13

Uterus 8

Leukemia and lymphoma 6

Cancer incidence by site and sex in Jordan (1997)

Male Type Percent

Bladder 10.5

Lungs 10.3

Leukemia 9

Prostate 7.3

Lymphoma 6.6

Brain & CNS 5.8

Skin 5.8

Stomach 4.9

Colon 4.4

Larynx 3.8

Cancer incidence by site and sex in Jordan (1997)

Female: Type Percent

Breast 28.3

Skin 5.9

Leukemia 5.4

Lymphoma 5.1

Colon 5

Uterus 4.5

Thyroid 4.5

Brain & CNS 4

Stomach 3.1

Cervix 2.9

Risk factors for cancer (1)

some are controllable; some are not

Heredity:

5 – 10% of cancers; documented with some breast and colon cancers

Age:

70% of all cancers occur in persons > 65

Lower socio-economic status

Stress

Leads to greater wear and tear on body in general

5. Diet:

Certain preservatives in pickled

Salted foods;

Fried foods;

High-fat, low fiber foods;

High fat foods

Diet high in red meat

Risk factors for cancer (1)

Occupational risk:

Exposure to know carcinogens, radiation, high stress

Infections:

Especially specific organisms and organ (e.g. papillomavirus causing genital warts and leading to cervical cancer.

Tobacco Use:

Lung

Oral

Laryngeal

Esophageal

Gastric

Pancreatic

Bladder

Alcohol Use:

Same as smoking

Sun Exposure (radiation):

Skin cancer

Nursing role:

Health promotion to lower risks

Routine medical check up and screenings

Client awareness to act if symptoms of cancer occur

Screening examination recommendations by American Cancer Society; specifics are made according to age and frequencies

ACS: recommendation for screening

Breast Cancer:

Self-breast exam

Breast examination by health care professionals

Screening mammogram

Colon and Rectal Cancer:

fecal occult blood

Flexible sigmoidoscopy

Colonoscopy

Cervical, Uterine Cancer:

Papanicolaou (Pap) test

Prostate Cancer:

Digital rectal exam

Prostate-specific antigen (PSA) test

Theories of Carcinogenesis

Cells begin to mutate:

Change the DNA to unnatural cell reproduction

Oncogenes/Tumor Suppressor Genes Abnormalities:

Oncogenes are genes that promote cell proliferation and can trigger cancer

Tumor suppressor genes normally suppress oncogenes but are damaged

Exposure to Carcinogens (1)

Act by directly altering the cellular DNA (genotoxic)

Act by affecting the immune system (promotional)

Depends on:

Dose (amount)

Duration (time)

Exposure to Carcinogens (2)

Viruses

Viruses break the DNA chain and mutates the normal cells DNA

Epstein-Barr virus

Human papilloma virus

Hepatitis virus

Drugs and Hormones

Sex hormones often affect cancers of the reproductive systems (estrogen in some breast cancers; testosterone in prostate cancer)

Glucocorticoids and steroids alter immune system

Exposure to Carcinogens (3)

Chemical Agents

Industrial and chemical

Can initiate and promote cancer

Examples: hydrocarbons in soot ; arsenic in pesticides; chemicals in tobacco

Physical Agents

Exposure to radiation

Ionizing radiation found in x-rays, radium, uranium

UV radiation

Sun, tanning beds

Immune function

Protects the body from cancerous cells

Increased rate of cancer in immunocompromised patients

Types of neoplasms

Benign:

Localized growths respond to body’s homeostatic controls

Encapsulated

Stop growing when they meet a boundary of another tissue

Can be destructive

Malignant

Have aggressive growth, rapid cell division outside the normal cell cycle

Not under body’s homeostatic controls

Cut through surrounding tissues causing bleeding, inflammation, necrosis (death) of tissue

Metastasis:

Malignant tumors (neoplasm) can metastasize

Tumor cells travel through blood or lymph circulation to other body areas and invade tissues and organs there.

Primary tumor:

The original site of the malignancy

Secondary tumor (sites):

Areas where malignancy has spread i.e. metastasis (metastatic tumor)

Common sites of metastasis are lymph nodes, Liver, Lungs, Bones, Brain

50 – 60 % of tumors have metastasized by time primary tumor identified

Characteristics of neoplasms (1)

Cancerous cells must avoid detection by immune system

Malignant neoplasms can recur after surgical removal of primary and secondary tumors and other treatments

Malignant neoplasms vary in differentiation.

Highly differentiated are more like the originating tissue

Undifferentiated neoplasms consist of immature cells with no resemblance to parent tissue and have no useful function

Characteristics of neoplasms (2)

Malignant cells progress in deviation with each generation and do not stop growing and die, as do normal cells

Malignant cells are irreversible, i.e. do not revert to normal

Malignant cells promote their own survival by hormone production, cause vascular permeability; angiogenesis; divert nutrition from host cells

Effects of Cancer (1)

Disturbed or loss of physiologic functioning, from pressure or obstruction

Anoxia

Necrosis of organs

Loss of function:

Bowel or bladder obstruction

Increased intracranial pressure

Interrupted vascular/venous blockage

Ascites

Disturbed liver functioning

Motor and sensory deficits

Cancer invades bone, brain or compresses nerves

Respiratory difficulties

Airway obstruction

Decreased lung capacity

Effects of Cancer (2)

Hematologic Alterations:

Impaired function of blood cells

Secondary to any cancer that invades the bone marrow (leukemia)

May also be caused by the treatment

Abnormal WBCs: impaired immunity

Diminished RBCs

Diminished Platelets: anemia and clotting disorders

Effects of Cancer (3)

Infections: fistula development and tumors may become necrotic; erode skin surface

Hemorrhage: tumor erosion, bleeding, severe anemia

Anorexia-Cachexia Syndrome: wasting away of client

Unexplained rapid weight loss, anorexia with altered smell and taste

Catabolic state: use of body’s tissues and muscle proteins to support cancer cell growth

Effects of Cancer (4)

Paraneoplastic Syndromes:

Ectopic sites with excess hormone production

Parathyroid hormone (hypercalcemia)

Ectopic secretion of insulin (hypoglycemia)

Antidiuretic hormone (ADH: fluid retention)

Adrenocorticotropic hormone (ACTH)

Effects of Cancer (5)

Pain: major concern of clients and families

Types of cancer pain

Acute: symptom that led to diagnosis

Chronic: may be related to treatment or to progression of disease

Causes of pain

Direct tumor involvement including metastatic pain

Nerve compression

Involvement of visceral organs

Effects of Cancer (6)

Physical Stress:

body tries to respond and destroy neoplasm

Fatigue

Weight loss

Anemia

Dehydration

Electrolyte imbalances

Effects of Cancer (7)

Psychological Stress

Cancer equals death sentence

Guilt from poor health habits

Fear of pain, suffering, death

Stigmatized

Collaborative Care (Diagnostic Tests) (1)

Used to diagnose cancer

Determine location of cancer

X-rays

Computed tomography

Ultrasounds

Magnetic resonance imaging

Nuclear imaging

Angiography

Diagnostic Tests (2)

Diagnosis of cellular type of can be done through tissue samples from biopsies, shedded cells.

Cytologic Examination:

Tissue examined under microscope

Identification System of Tumors:

Classification

Grading

Staging

Diagnostic Tests (3)

Classification:

according to the tissue or cell of origin, e.g. sarcoma, from supportive

Grading:

Evaluates degree of differentiation and rate of growth

Grade 1 (least aggressive) to Grade 4 (most aggressive)

Staging:

Relative tumor size and extent of disease

TNM (Tumor size; Nodes: lymph node involvement; Metastases)

Diagnostic Tests (4)

Tumor markers: specific proteins which indicate malignancy

PSA (Prostatic-specific antigen): prostate cancer

CEA (Carcinoembryonic antigen): colon cancer

Alkaline Phosphatase: bone metastasis

Diagnostic Tests (5)

Direct Visualization

Sigmoidoscopy

Cystoscopy

Endoscopy

Bronchoscopy

Exploratory surgery

Lymph node biopsies to determine metastases

Diagnostic Tests (6)

Other non-specific tests

CBC, Differential

Electrolytes

Blood Chemistries:

Liver enzymes

RFT

Treatment (1)

Treatment Goals: depending on type and stage of cancer

Cure

Recover from specific cancer with treatment

Alert for reoccurrence

May involve rehabilitation with physical and occupational therapy

Control: of symptoms and progression of cancer

Continued surveillance

Treatment when indicated (e.g. some bladder cancer, prostate cancer)

Palliation of symptoms: may involve terminal care if client’s cancer is not responding to treatment

Treatment Options

Depend on type of cancer:

Alone or in combination

Chemotherapy (1)

Effects are systemic and kills the metastatic cells

Often combinations of drugs in specific protocols over varying time periods

Much more effective then a single agent

Consider the timing of the nadir of each drug

The time when the bone marrow activity and WBC counts are at their lowest levels after chemo

Different times for different drugs

Cell-kill hypothesis:

with each cell cycle a percentage of cancerous cells are killed but some remain; repeating chemo kills more cells until those left can be handled by body’s immune system

Classes of Chemotherapy Drugs (1)

Alkylating agents

Action: create defects in tumor DNA

Examples: Nitrogen Mustard, Cisplatin

Antimetabolites:

Action: similar to metabolites needed for vital cell processes

Metabolites interfere with cell division

Examples: Methotrexate; 5 fluorouracil

Toxic Effects: nausea, vomiting, stomatitis, diarrhea, alopecia, leukopenia

Antitumor Antibiotics:

Action: interfere with DNA

Examples: Actinomycin D, Bleomycin

Toxic Effect: damage to cardiac muscle

Classes of Chemotherapy Drugs (2)

Antimiotic agents

Action: Prevent cell division

Examples: Vincristine, Vinblastine

Toxic Effects: affects neurotransmission, alopecia, bone marrow depression

Hormone agonist

Action: large amounts of hormones upset the balance and alter the uptake of other hormones necessary for cell division

Example: estrogen, progestin, androgen

Classes of Chemotherapy Drugs (3)

Hormone Antagonist

Action: block hormones on hormone-binding tumors (breast, prostate, and endometrium); cause tumor regression

Decreasing the amount of hormones can decrease the cancer growth rate

Does not cure, but increases survival rates

Examples: Tamoxifen (breast); Flutamide (prostate)

Toxic Effects: altered secondary sex characteristics

Classes of Chemotherapy Drugs (4)

Hormone inhibitors

Aromatase inhibitors (Arimidex, Aromasin)

Prevents production of aromatase which is needed for estrogen production

Used in post menopausal women

Side effects (Masculinizing effects in women, Fluid retention)

Effects of Chemotherapy

Tissues (fast growing) frequently affected

Examples:

Mucous membranes

Hair cells

Bone marrow

Specific organs with specific agents, reproductive organs (all fetal toxic, impair ability to reproduce).

Administration of chemotherapeutic agents

Trained and certified personnel, according to established guidelines

Preparation

Protect personnel from toxic effects

Drugs absorbed through skin and mucous membranes

Protective clothing and extreme care

Extreme care for correct dosage; double check with physician orders, pharmacist’s preparation

Proper management clients’ stool

Routes

Oral

Body cavity (intraperitoneal or intrapleural)

Intravenous

Use of vascular access devices because of threat of extravasation (leakage into tissues) and long-term therapy

If the drug is a vessicant it may result in pain, infection and tissue loss

Types of vascular access devices

PICC lines (peripherally inserted central catheters)

Tunnelled catheters (Hickman, Groshong)

Surgically implanted ports (accessed with 90o angle needle)

Portacath

PICC Line

Managing side effects of chemotherapy (1)

Nausea and vomiting

80% of patients will develop it

Antiemetics such as:

Zofran

Tigan

Compazine

Ativan to control the symptoms

Monitor for dehydration and need for IV fluids

Managing side effects of chemotherapy (2)

Bone marrow suppression

Decreased number of RBC

Leads to hypoxia, fatigue

Hgb 9.5-10 gm/dl require oral iron supplements

Hgb below 8 gm/dl require transfusion

May use Epogen to stimulate RBC production

Managing side effects of chemotherapy (3)

Decrease number of WBC (normal 4,500-11,000 mm3) especially neutrophils (normal 3,000-7,000 cells/cc)

Neutropenia-count below 2000

Patient at extreme risk for infection

May order granulocyte colony stimulating factor (leukine) to stimulate bone marrow to increase WBC count

Neutropenic precautions

Private room

Good handwashing

Monitor temp q 4 hours, monitor for chills, UTI, pneumonia

Limit visitors to healthy adults

No flowers or plants

Monitor neutrophil count

Managing side effects of chemotherapy (4)

Thrombocytopenia

Drop in platlet count (normal 150,000-400,000/mm3) below 100,000

Test pt for bleeding in stool and urine

Avoid punctures for IV or IM

Handle pt gently

Use electric razor

Avoid placing foley or rectal thermometers

Avoid oral trauma with soft bristle brushes, avoid flossing, avoid hard candy

Watch for LOC, pupil changes that might indicate intracranial bleeds

Stool softeners to avoid straining

Managing side effects of chemotherapy (5)

Mucocitis

Inflammation and ulceration of mucous membranes and entire GI tract

Rinse mouth with ½ normal saline and ½ peroxide every 12 hours

Topical analgesic medication

Avoid mouthwashes with alcohol

Avoid spicy or hard food

Watch nutritional status

Managing side effects of chemotherapy (6)

Alopecia

Hair loss

2-3 weeks after treatment is started

Affects all the hair, including eyebrows, eyelashes

Within 4-8 weeks after treatment hair begins to grow back

Before hair loss, have the pt pick out a wig that is similar to hair color

Managing side effects of chemotherapy (7)

Peripheral neuropathy

Numbness and tingling to fingers and toes in a glove and sock pattern

May cause gait and possible fall problems

Provide emotional and spiritual support to patient and families

Surgery

Diagnosis, staging, and sometimes treatment of cancer

May be prophylaxis or removal of at risk tissue or organ prior to development of cancer (breast cancer)

Involves removal of body part, organ, sometimes with altered functioning (e.g. colostomy)

Debulking (decrease size of) tumors in advanced cases

Reconstruction and rehabilitation (e.g. breast implant post mastectomy)

Palliative surgery to improve the quality of life

Removal of tumor tissue that is causing pain or obstruction

Psychological support to deal with surgery as well as cancer diagnosis

Radiation Therapy (1)

Treatment of choice for some tumors to kill or reduce tumor, relieve pain or obstruction

Destroy cancer cells with minimal exposure to normal cells

Cells die or are unable to divide

Delivery

Teletherapy (external): radiation delivered in uniform dose to tumor

Beam radiation

Brachytherapy: delivers high dose to tumor and less to other tissues; radiation source is placed in tumor or next to it in the form of seeds

Radiation source within the patient so pt emits radiation for a period of time and is a hazard to others

Combination

Radiation Therapy (2)

Goals

Maximum tumor control with minimal damage to normal tissues

Caregivers must protect selves by using shields, distancing and limiting time with client, following safety protocols

Private room

Caution sign on the door for radioactive material

Dosimeter film badge by staff

No pregnant staff

Limit visitors to ½ hour per day and keep them at least 6 ft from the source

Radiation Therapy (3)

Treatment Schedules

Planned according to radiosensitivity of tumor, tolerance of client

Monitor blood cell counts

5. Side Effects

Skin (external radiation): blanching, erythema, sloughing, breakdown

Use mild soak

Dry skin with a patting motion, not rubbing

Don’t use powders or lotions unless prescribed by radiologist

Wear soft clothing over the site

Avoid the sun and heat

Radiation Therapy (4)

b. Ulcerated mucous membranes: pain, lack of saliva (xerostoma)

c. Gastrointestinal: nausea and vomiting, diarrhea, bleeding, sometimes fistula formation

d. Radiation pneumonitis

1-3 months after treatment

Cough, SOB, fever

Treated with steroids to decrease inflammation

Biological Response Modifiers

Monoclonal antibodies (inoculate animal with tumor antigen and retrieve antibodies against tumor for human)

Antibodies target specific substances needed by the cancer cell for growth (Herceptin for breast cancer)

Gene therapy

experimental

May insert gene into the tumor cells to make them more susceptible to being killed by antiviral agents

May insert genes for cytokines that increase their effectiveness in killing cancer cells

Angiogenesis inhibitor drugs

Prevent new blood vessels from forming and delivering blood to the tissue

Bone Marrow Transplant (BMT)

Bone Marrow Transplantation and Peripheral Blood Stem Cell Transplantation

Stimulation of nonfunctioning marrow or replace bone marrow

Common treatment for leukemias

Pain Control

Includes pain directly from cancer, treatment, or unrelated

Necessary for continuing function or comfort in terminally ill clients

Goal is maximum relief with minimal side effects

Multiple:

Combinations of analgesics (narcotic and non-narcotic)

Adjuvants such as steroids or antidepressants

Iincludes around the clock (ATC) schedule with additional medications for break-through pain

Routes of medications

May involve injections of anesthetics into nerve, surgical severing of nerves radiation

May need to progress to stronger pain medications as pain increases and client develops tolerance to pain medication

Nursing Diagnoses for Clients with Cancer

Anxiety

Therapeutic interactions with client and family

Community resources

الملاذ

KHCC

Availability of community resources for terminally ill

Disturbed Body Image:

Includes:

Loss of body parts (e.g. amputations)

Appearance changes (skin, hair)

Altered functions (e.g. colostomy);

Cachexic appearance

Loss of energy

Ability to be productive

Fear of rejection, stigma

Anticipatory Grieving

Facing death and making preparations for death

Offer realistic hope that cancer treatment may be successful

Risk for Infection

Risk for Injury

Organ obstruction

Pathological fractures

Altered Nutrition: less than body requirements

Consultation with dietician

Lab evaluation of nutritional status

Managing problems with eating: anorexia, nausea and vomiting

May involve use of parenteral nutrition

Impaired Tissue Integrity

Oral, pharyngeal, esophageal tissues (due to chemotherapy, bleeding due to low platelet counts, fungal infections such as thrush)

Teach inspection, frequent oral hygiene, specific non-irritating products, thrush control

Oncologic Emergencies

Pericaridal Effusion and Neoplastic Cardiac Tamponade

Concern:

Compression of heart by fluid in pericardial sac

Compromised cardiac output

Treatment:

Pericardiocentesis

Superior Vena Cava Syndrome

Obstruction of venous system with increased venous pressure and stasis

Facial and neck edema

Respiration distress

Late signs are:

Cyanosis

Decreased cardiac output

Hypotension

Treatment:

Respiratory support

Decrease tumor size with radiation or chemotherapy

Compression of the superior vena cava in SVC syndrome

Sepsis and Septic Shock

Early recognition of infection

Patients at risk secondary to low WBC and impaired immune system

Treatment:

Prompt intervention with:

Antibiotics

Vasopressors

Disseminated Intravascular Coagulophathy (DIC)

Triggered by severe illness, usually sepsis in cancer patients

Abnormal clotting uses up existing clotting factors and platelets quickly then the pt hemorrhages

Mortality rate is 70%

Prevention of sepsis is key

Spinal Cord Compression

Pressure from expanding tumor or vertebral collapse can cause irreversible paraplegia

Back pain initial symptom with progressive Paresthesia and paralysis

Paralysis is usually permanent

Treatment:

Early detection

High dose corticosteroid to decrease the swelling

Radiation or Surgical decompression

Obstructive Uropathy

Concern:

Blockage of urine flow

Undiagnosed can result in renal failure

Treatment:

Restore urine flow

Hypercalcemia

High calcium (normal 9-10.5)

Usually from bone metastases

May also come from cancer of the lung, head, neck, kidney and lymph nodes that secrete parathyroid hormone that causes the bone to release calcium

Symptoms include:

Fatigue, Muscle weakness, Polyuria, Constipation, progressing to Coma, Seizures

Treatment:

Restore fluids with intravenous saline which also increases the excretion of calcium

Loop diuretics increase calcium excretion

Calcium chelators such as mithracin, Inhibit calcium resorption from the bone

Calcitonin di-phosphonate

Tumor Lysis Syndrome

Occurs with rapid necrosis of tumor cells with chemotherapy:

When tumor cells die they release potassium and purines

Potassium (norm 3.5-5.5)

Elevation Potassium causes:

Cardiac arrhthymias, Muscle weakness, Twitching, Cramps

Purines convert to uric acid which causes:

Renal failure, Flank pain, Gout when elevated above 10 mg/dl

Hyperphosphatemia with secondary to hypocalcemia causes:

Heart block, HTN, Renal failure

Treatment

Hydration

Instruct pt to increase fluid intake before and after chemo

May need IV hydration

Diuretics to increase urine flow

Allopurinol to increase uric acid excretion

May need dialysis

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)

Ectopic ADH production from tumor leads to excessive hyponatremia

Holds onto too much fluid which decreases sodium level (normal 135-145)

Symptoms

Weakness, Muscle cramps, Fatigue, ALOC, Headache, Seizures

Treatment:

Restore sodium level, Fluid restriction, Increase sodium, Antibiotic, Demeclocycline works in opposition to ADH and Limits ADH effect on distal renal tubules so they can excrete water

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